Request for Screening

Required fields are marked with asterisks (*)

If you have received a Penalty Notice and believe you did not either contravene the by-law, violate the by-law or commit the by-law infraction as indicated, you can complete this form to have it reviewed by a Screening Officer.

Please note that Screening decisions are made in accordance with the Township’s Administrative Penalty By-laws.

The Screening Officer may cancel an Administrative Penalty or change the amount if you prove that you did not contravene the by-law or that the amount causes you undue hardship.

The Screening process is to review and determine whether or not the infraction was committed. Each Screening appointment will be afforded up to 15-minutes for parking infractions and up to 30 minutes for non-parking infractions.

The Township of Wainfleet does not provide language interpreters, should you require one, you will be responsible for providing your own.

Penalty Notice Recipient

Name:

Email Address:

Phone Number:

Street Address:

Unit #:

City/Town:

Province:

Postal Code:

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice

Penalty Notice #:

Penalty Date:

Plate Number or Name:

Offence:

Section Number:

Type of Screening Requested

You are required to select one preferred method of Screening.

Please note: A Written Screening allows your Screening to be processed without your attendance.

Scheduled Screenings will be booked for the next available business day. A notice will be sent to you confirming the date and time of your Screening appointment. Once booked, Screening appointments cannot be rescheduled or adjourned.

Telephone and electronic Screenings may be recorded. By participating in a telephone or electronic meeting, you are consenting to being recorded.

Please select a method for your Screening:

Reason for Screening

You are required to provide specific information about why you believe you did not contravene the by-law and/or why the Screening Officer should change the Administrative Penalty amount.

If you are claiming financial hardship, you must provide documented proof of financial hardship. You will be able to attach that proof to this request.

You will also be able to attach any other documents or photographs you want the Screening Officer to review.

Please indicate the primary reason for requesting a Screening review:

I acknowledge that the Screening Officer will render a decision in accordance with our governing By-laws:

Please provide a factual and detailed explanation of the reason(s) for your Screening request AND the remedy you are seeking:

You may upload relevant images or files.

Statement of Penalty Notice Recipient

By signing below, I represent and warrant that:

I am the registered owner of the vehicle (for Parking Penalty Notices only); or
I am the person named on the Penalty Notice (for Non-Parking Penalty Notices only);
I acknowledge that if I fail to attend and to remain at my scheduled Screening until my matter has been determined by the Screening Officer, I will be deemed to have abandoned my request for a Screening, The Administrative Penalty will be affirmed, and I will be liable for an additional fee for having failed to attend ($50.00 for Parking and $100.00 for Non-Parking), and
I have read and understand the conditions of this application.

Signature:

Sign above

I would like a copy of my submission for my records.

CAPTCHA

Alerts

Wainfleet Multi-Year Accessibility Plan Invitation

Request for Screening

Penalty Notice Recipient

Penalty Notice Information (Infraction)

Type of Screening Requested

Reason for Screening

Statement of Penalty Notice Recipient